Information Collection

Certification of Funeral Expenses

IC 13646 under ICR 201506-1240-008 · OMB 1240-0040.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0040 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form LS-265 Certification of Funeral Expenses	Form
LS-265 Certification of Funeral Expenses ls-265.pdf www.dol.gov/owcp/dlhwc/ls-265.pdf	Form
DLHWC Seaportal.pdf DLHWC SEA Portal	IC Document

IC Title:

Certification of Funeral Expenses

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 702.121

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	LS-265	Certification of Funeral Expenses	ls-265.pdf	http://www.dol.gov/owcp/dlhwc/ls-265.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: DOL/GOVT-15

FR Citation: 67 FR 16870

Number of Respondents: 75

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	75	0	75
Annual IC Time Burden (Hours)	19	0	19
Annual IC Cost Burden (Dollars)	34	-5	39

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
DLHWC SEA Portal	DLHWC Seaportal.pdf	09/24/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.